B. Description of Supplements - California

1. Definitions of State Living Arrangement Variations

Lives in his/her own household, as defined for Federal living arrangement A purposes,
and has cooking and food storage facilities or is provided meals as part of the living
arrangement; or

2.

Is a patient in a certified private medical facility where title XIX does not pay more than 50 percent of the cost of care; or

3.

Is a blind child under age 18 living in the household of a parent or parents or is
a disabled child age 18 or over who meets sharing criteria and is living in the household
of a parent or parents; or

4.

Is a blind individual who lives in an independent living arrangement with or without
cooking and food storage facilities; or

5.

Lives in a private medical facility licensed by the State but not certified under
title XIX.

B

Non-medical Out-of-Home Care (NMOHC) -- Applies when an individual/couple needs non-medical
care or supervision in the following living arrangement situations:

CHILDREN
(UNDER AGE 18)

1. Blind child residing in a State licensed NMOHC facility; or

2. Blind child residing in the home of a relative who is not a parent and not a legal
guardian; or

3. Disabled child residing in a State licensed NMOHC facility; or

4. Disabled child residing in the home of a legal guardian who is not a relative;
or

5. Disabled child residing in the home of a relative who is not a parent (Major v. McMahon decision) ; or

6. A blind or disabled child in a “certified family” home approved by a licensed home-finding
agency (“certified family home placement”); or

ADULTS
(AGE 18 AND OVER)

7. Aged, blind or disabled individual/couple has been determined to be in FLA A and
resides in the home of a relative, legal conservator or guardian; or

8. Aged, blind or disabled individual/couple has been determined to be in FLA A and
resides in a State licensed NMOHC facility.

For California optional supplement purposes, a relative is defined as a parent, son,
daughter, brother, sister, half-brother, half-sister, uncle, aunt, niece, nephew,
first cousin, or any person of the preceding generation denoted by the prefix “grand”
or “great.”

C

Independent Living Without Cooking Facilities -- Aged or disabled individual/couple
who is neither provided any meals nor has access to adequate cooking/food storage
facilities as part of a living arrangement. Transients, as defined in SI 00835.060, are also eligible for OS C.

An individual/couple qualifies for OS C if any of the following situations exists:

1.

Immediate living quarters do not have cooking and food storage facilities with which
the individual/couple or another person (who is responsible for preparing the individual's/couple's
meals) can prepare meals on a daily basis.

2.

Does not have access to adequate cooking and food storage facilities as part of the living
arrangement (including cooking and food storage facilities which are outside the immediate
living quarters) for the purpose of preparing meals or having them prepared on their
behalf.

3.

Lives in a boarding house that does not have a communal kitchen with adequate cooking and food storage facilities to which
they have access for preparation of meals.

4.

Lives with friends or relatives in private living quarters in the same house or in
separate living quarters (for example, “over the garage”) or in a similar situation
and does not have access to the cooking and food storage facilities in the main residence for preparation
of meals.

5.

Lives in a room and board facility and does not contract with the facility to have meals prepared and provided as part of the living
arrangement (for example, the SSI applicant's/recipient's arrangement with the facility
is to purchase only shelter on a monthly basis).

“Adequate” cooking and food storage facilities exist when an individual/couple has
access to:

•

Both a working refrigerator or icebox and a stove without a working oven but with at least two working burners. (The capacity
of the refrigerator or icebox is not a factor of consideration. An ice chest is not considered adequate storage.)

OR

•

Both a working refrigerator or icebox and a hotplate with at least two burners with separate temperature controls, or two one-burner
hotplates with temperature controls. (Hotplates without temperature controls that
are used for warming food are not considered adequate cooking facilities.)

OR

•

Both a working refrigerator or icebox and a stove with a working oven or functioning microwave oven in combination with at least
one working burner on a stove or a one-burner hotplate with a temperature control.

Eligibility for OS C begins in the month the applicant/recipient applies for this
supplement rate provided he/she has been without cooking and food storage facilities
throughout the month.

NOTE: For purposes of OS C, “throughout a month” does not mean the applicant/recipient must lack adequate cooking/food storage facilities from
the very first moment of the month. He/she need only lack them from some time on the
first day of the month.

If eligibility is based on temporary loss or nonfunctioning of an appliance, the individual
should be advised of his/her responsibility to report immediately when the temporary
condition has ceased. If the individual provides an expected date when the appliance
will be replaced/repaired, diary the case for re-contact.

Eligibility for this supplementary payment ceases the month following the month in
which meals are provided or adequate cooking and food storage facilities are available.

For a couple, comprised of an aged/disabled individual and a blind individual, whose
living arrangement lacks adequate cooking and storage facilities, the couple is to
receive the SSI/SSP level for a blind/aged or disabled couple plus the restaurant
meals allowance for the disabled member of the couple. Force payment in this living
arrangement is required.

D

Living in the Household of Another -- Eligible individual/couple is living in the
household of another and is receiving food and shelter from that individual. Most individuals/couples who are subject to a 1/3 reduction
of their Federal SSI payments (VTR) are eligible for OS D because the criteria for
this supplement level are the same as for charging the VTR. However, when the eligible
individual/couple lives in the home of a relative (other than a spouse) and needs
care and supervision, certification for non-medical out-of-home care (OS F) should
be obtained from the county welfare office since this is the highest categorical supplement
for which an individual /couple can qualify.

E

Disabled Child Under Age 18 – Disabled (not blind) child under age 18 who resides
with a parent or relative by blood or marriage.

NOTE: Only FLA A and C are compatible with OS E. If the VTR applies, see code G.

F

Non-medical Out-of-Home Care Living in the Household of Another -- . Applies whenever
an eligible individual or couple meets the criteria for the non-medical out-of-home
care payment rate, and is determined to receive the Federal code B payment for living
in the household of another (SI 00835.200).

G

Disabled Child Under Age 18 Living in the Household of Another --. Applies to a disabled
(not blind) child under age 18, who resides with a parent or relative by blood or
marriage, and is determined to receive the Federal code B payment for living in the household of
another individual (SI 00835.200).

J

Residents of title XIX facilities.

This State code is also used to supplement Section 1619 cases.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- Eligible individual or couple who is a patient:

1.

In a medical facility where title XIX pays more than 50 percent of the costs; or

2.

In a private medical facility which is not certified under title XIX and not licensed
by the State.

Includes residents of publicly operated emergency shelters throughout a month.

NOTE: California is a concurrent category State and permits SSI recipients to receive the
highest categorical supplement for which they can qualify.

1Not a Federal benefit rate (FBR); the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

Aged/Aged

934.00

568.00

1502.00

Blind/Blind

934.00

795.00

1729.00

Disabled/Disabled

934.00

568.00

1502.00

Aged/Blind

934.00

710.00

1644.00

Aged/Disabled

934.00

568.00

1502.00

Blind/Disabled

934.00

710.00

1644.00

B

All

934.00

1136.00

2070.00

C

Aged/Aged

934.00

736.00

1670.00

Disabled/Disabled

934.00

736.00

1670.00

Aged/Disabled

934.00

736.00

1670.00

Z

All

934.00

0.00

934.00

B

D

Aged/Aged

622.671

595.66

1218.33

Blind/Blind

622.671

822.66

1445.33

Disabled/Disabled

622.671

595.66

1218.33

Aged/Blind

622.671

736.66

1359.33

Aged/Disabled

622.671

595.66

1218.33

Blind/Disabled

622.671

736.66

1359.33

F

All

622.671

1045.66

1668.33

D

J

All

60.002

40.00

100.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

C. Description of Supplements - Delaware

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Adult Residential Care Facility, Assisted Living Facility, or Adult Foster Care Home
-- Only living arrangement variation in Delaware and includes only those recipients
who are certified by the State medical unit as residents of one of the above adult
facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- All recipients who are not included in A or Y.

Optional supplementation code Z is the proper code to be used with an “intervening”
Federal code A. (See SM 01301.535)

2. Coding and Monthly Payment Levels

Delaware effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

TotalPayment Levels

A

A

All

623.00

140.00

763.00

Z

All

623.00

0.00

623.00

B

Z

All

415.341

0.00

415.34

C

Z

All

623.00

0.00

623.00

D

Z

All

30.002

0.00

30.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

All

934.00

448.00

1382.00

Z

All

934.00

0.00

934.00

B

Z

All

622.671

0.00

622.67

D

Z

All

60.002

0.00

60.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

D. Description of Supplements - District of Columbia

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Adult Foster Care Home with 50 or Fewer Residents --Recipients who are certified by
the District of Columbia, Department of Human Services, as residents of an adult foster
care home with 50 or fewer residents.

B

Adult Foster Care Home with More than 50 Residents --Recipients who are certified
by the District of Columbia, Department of Human Services, as residents of an adult
foster care home with more than 50 residents.

G

Residents of title XIX facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- All recipients who are not included in A, B, G, or Y.

2. Coding and Monthly Payment Levels

District of Columbia effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

All

623.00

485.00

1108.00

B

All

623.00

595.00

1218.00

B

Z

All

415.341

0.00

415.34

C

Z

All

623.00

0.00

623.00

D

G

All

30.002

40.00

70.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Code

Total Payment Levels

A

A

All

934.00

1282.00

2216.00

B

All

934.00

1502.00

2436.00

B

Z

All

622.671

0.00

622.67

D

G

All

60.002

80.00

140.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

E. Description of Supplements - Hawaii

1. Definitions of State Living Arrangement Variations

Code

Definition

B

Living in a Community Care/Foster Care Home --

Persons eligible for SSI and who are both over age 18 and live in a State approved
Care/Foster Care Home.

H

Domiciliary Care I -- (Maximum of five residents) - Eligible individual (including
a child) or couple living in a domiciliary care facility which provides varying levels
of care and services. A domiciliary care facility is a private, non-medical facility
established and maintained to provide personal care and services to aged, infirm,
or handicapped persons. The State provides SSA with listings of these facilities.

I

Domiciliary Care II -- Same as H except care is provided for six or more residents.

Y

Optional Supplementation Waived -- Eligible for, but has waived his/her right to receive
an optional supplement.

Z

No Supplement Cases -- Eligible individual (or couple) who is living in the household
of another (see explanation in definition for optional supplement B) and an eligible
individual (or couple) who is a patient:

1.

In a medical facility where title XIX pays more than 50 percent of the costs; or

2.

In a private medical facility which is not certified under title XIX.

Also includes residents of publicly operated emergency shelters throughout a month.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

B

All

934.00

1555.80

2489.80

H

All

934.00

1555.80

2489.80

I

All

934.00

1771.80

2705.80

B

Z

All

622.671

0.00

622.67

D

Z

All

60.002

0.00

60.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

F. Description of Supplements - Iowa

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Living in Own Household (Blind Only) -- Only an eligible blind individual and the blind member
of a couple who does not live in any other State living arrangement variation, does not have an
EP, and is not otherwise excepted from supplementation. Also included are blind recipients in title XIX facilities where Medicaid pays 50 percent or less of the cost
of care. Optional supplement code A is also compatible with Federal codes A and C.

Optional supplement code A is the proper code to be used with an “intervening” Federal
code A. (See SM 01301.535)

B

Living in the Household of Another (Blind Only) -- Only an eligible blind individual and the blind member
of a couple who does not live in any other State living arrangement variation, lives in the household
of another for Federal purposes, does not have an EP, and is not otherwise excepted
from supplementation.

H

Living with a Dependent Person -- Eligible individual or each member of an eligible
couple in Federal living arrangement A, B, or C who has an ineligible spouse, parent,
child, or adult child living in the home with him or her, and who is financially dependent
upon the eligible individual as defined by the State Department of Human Services.

The payment level for this variation is increased by $22 for each blind individual
or blind member of a couple to reflect the categorical blind supplement.

I

Living in a Family Life or Boarding Home -- Eligible individual or each member of
an eligible couple in Federal living arrangement A or B who resides in a family life
home or boarding home licensed by the State Department of Health or certified by the
State Department of Human Services.

G

Used to indicate that no supplement is payable to a recipient living in a title XIX
facility and title XIX pays more than 50 percent of the cost of care; however, a Federal
D living arrangement is not appropriate because the “throughout a month” requirement
is not met at the time initial claims input is made.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- Residents of publicly operated emergency shelters throughout
a month and aged and disabled recipients living in their own households or living
in the households of others. No supplement also applies to all recipients living in
medical facilities not certified under title XIX or all recipients whose Federal payments
are reduced to $30/$60 due to living in a title XIX facility. In addition, aged and
disabled recipients whose Federal payments are not reduced and who live in a title
XIX facility where Medicaid pays 50 percent or less of the cost of care do not receive
a supplement.

NOTE: Iowa is a concurrent category State and permits SSI recipients to receive the highest
categorical supplement for which they can qualify.

Blind recipients (either individuals or member of a couple) whose records include
an EP have a supplementary payment level that includes $22 for each individual in
addition to the FBR and EP increment and must be force paid.

2. Coding and Monthly Payment Levels

Iowa effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

Blind

623.00

22.00

645.00

C

Aged

623.00

317.00

940.00

Blind

623.00

339.00

962.00

Disabled

623.00

317.00

940.00

D

All

623.00

142.00

765.00

Z

Aged

623.00

0.00

623.00

Disabled

623.00

0.00

623.00

B

B

Blind

415.341

22.00

437.34

H3

Aged

415.341

317.00

732.34

Blind

415.341

339.00

754.34

Disabled

415.341

317.00

732.34

I3

All

415.341

142.00

557.34

Z

Aged

415.341

0.00

415.34

Disabled

415.341

0.00

415.34

C

A

Blind

623.00

22.00

645.00

C

Blind

623.00

339.00

962.00

Disabled

623.00

317.00

940.00

Z

Disabled

623.00

0.00

623.00

D

Z

All

30.002

0.00

30.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

G. Description of Supplements - Massachusetts

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Full Cost-of-Living:

1.

An individual who is in Federal living arrangement A is in State living arrangement
A, if he/she is living in his/her own household1 and is:

a.

Living alone -- Individuals who live alone, who rent rooms in commercial rooming houses
which openly advertise to the public and which do not provide board, or who live in
a hotel. Also, those who rent only rooms in private residences will be considered
living alone provided they do not use the residential kitchen facilities for preparing
meals; or

b.

Living only with his/her eligible spouse; or

c.

Living with his/her eligible spouse and ineligible child/children 2 none of whom (children) receive public income maintenance payments;3 or

d.

Living only with his/her ineligible spouse and/or his/her ineligible child/children,
none of whom (spouse and children) receive public income maintenance payments.

NOTE: For purposes of 1.a. through 1.d., foster children placed with anyone other than
their parents are not considered to be living with the foster parent.

An individual who is in Federal living arrangement C is in State living arrangement
A if none of the other people with whom he/she is living receive public income maintenance
payments.

An individual who is in Federal living arrangement A or C and who does not meet the
criteria contained in SI 01415.038G.1. (See Code A, 1. or 2.) will be in State living arrangement A if he/she pays at
least two-thirds of the household expenses. In making a determination as to whether
the individual pays two-thirds or more of the expenses, use the method defined in
SI 00835.160. Only the household expenses shown in that section are to be used. An ineligible
spouse's income (except any assistance based upon need) may be used to determine if
the eligible person is paying two-thirds of the household expenses.

A person living in a public congregate housing development is in A. The State makes
the determination that a public congregate housing development is eligible for listing.
Optional supplement code A is the proper code to be used with an “intervening” Federal
code A. (See SM 01301.535.)

B

Shared Living Expenses -- An individual who is in Federal living arrangement A or
C and who does not meet the criteria listed for State living arrangement A, E or G
is in State living arrangement B. Also included in this living arrangement are transients,
the homeless, and residents of public emergency shelters for the homeless (PESH).

Those residing in group-care facilities such as halfway houses, private medical facilities
where Medicaid is paying 50 percent or less of the cost of care, foster homes, commercial
boarding homes, or other facilities which do not meet the criteria for living arrangement
E or public congregate housing defined in SI 01415.039G.1., Code A.4. This includes children under the age of 18 who are in Federal living
arrangement D because a private health insurance policy or a combination of Medicaid
and a private health insurance policy pays or is expected to pay over 50 percent of
the cost of care for that month. See SI 00520.011C.1.b, second and third bullets. Also included are individuals placed under the auspices
of the State adult foster care program and residents of publicly operated emergency
shelters throughout a month.

An individual living in a household where all members receive public income maintenance
payments unless he/she is paying at least two-thirds of the household expenses (A).

An individual living in a mixed household -- i.e., a household where one or more other
members receive a public income maintenance payment -- also is included unless the
individual is paying at least two-thirds of the household expenses (A).

C

Living in the Household of Another -- Recipients determined under Federal rules to
be living in the household of another and receiving support and maintenance which
reduce the Federal benefit by one-third.

E

Licensed Rest Home -- Persons residing in a licensed rest home, all of which or that
portion in which they are living is licensed by and has a provider agreement with
the State. Does not include residents of a Medicaid certified portion of a rest home.

F

Effective 7/1/87, the State elected Federal administration of this optional State
supplementary payment to residents of title XIX facilities where Medicaid pays more
than 50 percent of the cost of care. This includes children under the age of 18 for
whom Medicaid alone pays or is expected to pay over 50 percent of the cost of care
for that month.

G

Assisted Living -- Effective 7/1/94, the State elected Federal administration of this
variation. Includes an individual, certified by the State to be residing in an Assisted
Living residence served by a certified Group Adult Foster Care provider, who is not
receiving assistance under any other Federal or State rental assistance program, and
who pays a fixed, non-separable fee for rent and supportive services, other than medically
necessary services reimbursed by Medicaid. The State shall certify to SSA each individual
who is eligible for this optional supplement living arrangement. This living arrangement
was discontinued effective 1/1/96. However, it has been restored, retroactively, to
1/1/97.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

NOTE: Massachusetts is a concurrent category State and permits SSI recipients to receive
the highest categorical supplement for which they can qualify.

1For purposes of determining State living arrangements, a commercial boarding house,
foster home, or halfway house is not considered the person's household.

3A public income maintenance payment is a payment from any of the following programs:
TANF, SSI, the Refugee Act of 1980, the Disaster Relief Act of 1974, general assistance
programs of the Bureau of Indian Affairs, State or local government income maintenance
programs that are based on need, or Department of Veterans Affairs benefits based
on need.

2. Coding and Monthly Payments Levels

Massachusetts effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

Aged

623.00

128.82

751.82

Blind

623.00

149.74

772.74

Disabled

623.00

114.39

737.39

B

Aged

623.00

39.26

662.26

Blind

623.00

149.74

772.74

Disabled

623.00

30.40

653.40

E

Aged

623.00

293.00

916.00

Blind

623.00

149.74

772.74

Disabled

623.00

293.00

916.00

G

Aged

623.00

454.00

1077.00

Blind

623.00

454.00

1077.00

Disabled

623.00

454.00

1077.00

B

C

Aged

415.341

104.36

519.70

Blind

415.341

357.40

772.74

Disabled

415.341

87.58

502.92

C

A

Blind

623.00

149.74

772.74

Disabled

623.00

114.39

737.39

B

Blind

623.00

149.74

772.74

Disabled

623.00

30.40

653.40

D

B2

Blind

30.003

149.74

179.74

Disabled

30.003

30.40

60.40

F

All

30.003

35.00

65.00

1Not an FBR; the amount represents the FBR less VTR.

2State OS Code B applies to children under the age of 18 who are in Federal living
arrangement D because of private health insurance payments.

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

Aged/Aged

934.00

201.72

1135.72

Blind/Blind

934.00

611.48

1545.48

Disabled/Disabled

934.00

180.06

1114.06

Aged/Blind

934.00

406.60

1340.60

Aged/Disabled

934.00

190.89

1124.89

Blind/Disabled

934.00

395.77

1329.77

B

Aged/Aged

934.00

201.72

1135.72

Blind/Blind

934.00

611.48

1545.48

Disabled/Disabled

934.00

180.06

1114.06

Aged/Blind

934.00

406.60

1340.60

Aged/Disabled

934.00

190.89

1124.89

Blind/Disabled

934.00

395.77

1329.77

E

Aged/Aged

934.00

898.00

1832.00

Blind/Blind

934.00

611.48

1545.48

Disabled/Disabled

934.00

898.00

1832.00

Aged/Blind

934.00

754.74

1688.74

Aged/Disabled

934.00

898.00

1832.00

Blind/Disabled

934.00

754.74

1688.74

G

Aged/Aged

934.00

681.00

1615.00

Blind/Blind

934.00

681.00

1615.00

Disabled/Disabled

934.00

681.00

1615.00

Aged/Blind

934.00

681.00

1615.00

Aged/Disabled

934.00

681.00

1615.00

Blind/Disabled

934.00

681.00

1615.00

B

C

Aged/Aged

622.671

215.80

838.47

Blind/Blind

622.671

922.80

1545.47

Disabled/Disabled

622.671

194.18

816.85

Aged/Blind

622.671

569.30

1191.97

Aged/Disabled

622.671

204.99

827.66

Blind/Disabled

622.671

558.49

1181.16

D

F

All

60.002

70.00

130.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

H. Description of Supplements - Michigan

1. Definitions of State Living Arrangement Variations

Code

Definition

D

Domiciliary Care -- Recipients residing in licensed non-medical facilities that provide
room, board, and supervision. The State provides a list of these facilities and certifies
which recipients are residents requiring this level of care.

E

Personal Care -- Recipients residing in licensed non-medical facilities that provide
general supervision, physical care, and assistance in carrying out the basic activities
of daily living. The State provides a list of these facilities and certifies which
recipients are residents requiring this level of care. Such care situations include,
but are not limited to, licensed homes for the aged.

F

Home for the Aged -- Recipients residing in a non-medical facility for the aged. The
State provides SSA with a list of these facilities and certifies which recipients
are residents requiring this level of care.

G

Independent Living with an EP -- Recipients with an EP, not living in the household
of another. (Children under age 18 are excluded.)

H

Living in the Household of Another with an EP --Recipients with an EP and living in
the household of another for Federal purposes. (Children under age 18 are excluded.)

I

Effective 1/1/88, the State elected Federal administration of an optional State supplementary
payment to residents of title XIX facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- Recipients in title XIX facilities where Medicaid pays more
than 50 percent of the cost of care and recipients in medical facilities not certified
under title XIX.

2. Coding and Monthly Payment Levels

Michigan effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

D

All

623.00

87.00

710.00

E

All

623.00

157.50

780.50

F

All

623.00

179.30

802.30

G

All

935.002

14.00

949.00

B

H

All

623.341

9.33

632.67

D

I

All

30.003

7.00

37.00

1Not an FBR; the amount represents the FBR plus EP increment less VTR.

2Not an FBR; the amount represents the FBR plus EP increment.

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

D

All

934.00

486.00

1420.00

E

All

934.00

627.00

1561.00

F

All

934.00

670.60

1604.60

G

All

1246.002

21.00

1267.00

B

H

All

830.671

14.00

844.67

D

I

All

60.003

14.00

74.00

1Not an FBR; the amount represents the FBR plus EP increment less VTR.

2Not an FBR; the amount represents the FBR plus EP increment.

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

I. Description of Supplements - Montana

1. Definitions of State Living Arrangement Variations

Code

Definition

G

State-Certified Personal Care

H

State-Certified Residence in Group Home for Mentally Disabled

I

State-Certified Residence in Group Home for Physically or Developmentally Disabled

J

State-Certified Residence for Child and Adult Foster Care

K

State-Certified Transitional Living for Developmentally Disabled

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- Includes all individuals and couples not certified in State
codes G, H, I, J, or K.

2. Coding and Monthly Payment Levels

Montana effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

G

All

623.00

94.00

717.00

H

All

623.00

94.00

717.00

I

All

623.00

94.00

717.00

J

All

623.00

52.75

675.75

K

All

623.00

26.00

649.00

Z

All

623.00

0.00

623.00

B

Z

All

415.341

0.00

415.34

C

Z

All

623.00

0.00

623.00

D

Z

All

30.002

0.00

30.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

G

All

934.00

193.00

1127.00

H

All

934.00

193.00

1127.00

I

All

934.00

193.00

1127.00

J

All

934.00

110.50

1044.00

K

All

934.00

57.00

991.00

Z

All

934.00

0.00

934.00

B

Z

All

622.671

0.00

622.67

D

Z

All

60.002

0.00

60.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

J. Description of Supplements - Nevada

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Independent Living or Living in Parental Household -- Aged or blind eligible individual
or couple who:

1.

Lives in his/her own household as defined for Federal living arrangement A purposes;
or

2.

Is a patient in a certified private medical facility where title XIX does not pay more than 50 percent of the cost of care; or

3.

Is a blind child under age 18 (age 21 for individuals who qualify as a “protected
child”) living in a parent's household.

Used with an “intervening” Federal code A. (See SM01301.535.)

B

Living in the Household of Another -- Aged or blind eligible individual or couple
who is living in the household of another individual and receiving food and shelter from that individual. Aged or blind individuals or couples, who are subject
to a one-third reduction of their Federal SSI payment, are eligible for optional supplement
B because the criteria for this supplement level are the same as for Federal code
B.

C

Domiciliary Care -- Aged or blind eligible individual or couple who lives in a private
non-medical facility or, a residential facility serving 16 or fewer persons, which
provides personal care and services to aged, infirm, or handicapped adult persons
who are unrelated to the proprietor.

These facilities are licensed or authorized to receive payment by the State. The State
provides SSA with listings of these facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- No supplement cases include:

1.

Disabled eligible individuals or disabled members of eligible couples; or

2.

Eligible individuals or members of eligible couples in a medical facility where title
XIX pays more than 50 percent of the cost; or

3.

Eligible individuals or members of eligible couples who are patients in a private
medical facility which is not certified under title XIX; or

4.

Residents of publicly operated emergency shelters throughout a month.

NOTE: Nevada is a concurrent category State and permits SSI recipients to receive the highest
categorical supplement for which they can qualify.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

Aged/Aged

934.00

74.46

1008.46

Blind/Blind

934.00

374.60

1308.60

Aged/Blind

934.00

224.53

1158.53

Aged/Disabled

934.00

37.23

971.23

Blind/Disabled

934.00

187.30

1121.30

C

Aged/Aged

934.00

881.00

1815.00

Blind/Blind

934.00

881.00

1815.00

Aged/Blind

934.00

881.00

1815.00

Aged/Disabled

934.00

440.50

1374.50

Blind/Disabled

934.00

440.50

1374.50

Z

Disabled

934.00

0.00

934.00

B

B

Aged/Aged

622.671

49.64

672.31

Blind/Blind

622.671

531.94

1154.61

Aged/Blind

622.671

290.79

913.46

Aged/Disabled

622.671

24.82

647.49

Blind/Disabled

622.671

265.97

888.64

Z

Disabled

622.671

0.00

622.67

D

Z

All

60.002

0.00

60.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

K. Description of Supplements - New Jersey

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Congregate Care - Eligible individual/child/couple in Federal living arrangement (FLA)
A. The living arrangement includes the following: Recipients in residential facilities
who are under the supervision of the Department of Human Services: Children and adults
under the supervision of and/or placement by the NJ Department of Human Services’
Division of Developmental Disabilities (DDD) or Division of Youth and Family Services
(DYFS) who are in residential facilities (both in and outside of NJ); and Recipients
in Assisted Living Residences and in Comprehensive Personal Care Homes licensed by
the Department of Health and Senior Services.

B

Living Alone or with Others -- Eligible individuals (including children) or eligible
couples whose Federal living arrangements are A or C and who do not meet the requirements
defined in other supplementation categories.

Therefore, any eligible adult/couple who meets the requirement for a Federal code
A will be in optional supplement B unless residing in a residential health care facility
or living alone with an ineligible spouse.

Likewise, any child meeting the criteria for a Federal code C will automatically be
entitled to optional supplement B.

This category includes, but is not limited to, those eligible adults/couples who are:

1.

Living physically alone; or

2.

Living with others in a private dwelling, but meeting some criteria for Federal living
arrangement A; or

3.

Living in the Transitional Residency Program when the placement is through the Division
of Mental Health and Hospitals, Department of Human Services.

Optional supplement code B is the proper code to be used with an “intervening” Federal
code A. (See SM 01301.535.)

This State code is also used to supplement Section 1619 cases.

C

Living Alone with an Ineligible Spouse -- Used when an individual lives with his/her
ineligible spouse and there are no other persons who are part of the household. An
ineligible spouse for State supplementation purposes is determined by using Federal
criteria; i.e., a spouse, either by marriage or holding out who is either not eligible
for SSI or who chooses not to apply. The State uses this category to ensure that an
individual with an ineligible spouse will receive the same total payment as an eligible
couple or an individual with an EP. Once other persons, even minor children, are present
in the household, this supplementary payment variation cannot exist. However, it is
possible that a claimant and his/her ineligible spouse live with others and allege
that they are a separate “household” by virtue of the fact that they eat their meals
out or have separate purchase and preparation of food. In this instance, an optional
supplement C is permissible as long as no other person is in their “household.” There
is no couple counterpart in this category.

Parent(s) with minor children are always considered to be in the same household and
therefore the presence of minor children in the household of an ineligible spouse
would result in optional supplement B.

A transient individual who co-exists only with an ineligible spouse will also qualify
for the O/S - C rate.

D

Living in the Household of Another -- Persons who are “living in the household of
another” for Federal purposes.

Authorization to make this payment is based on the recipient's residence at a facility
listed in the New Jersey
Congregate Care Directory.

Only the RHCF section of a multipurpose facility is eligible for the OS “I” rate.
Residents of the ALR or CPCH section of a multipurpose facility are paid at the OS
“A” rate. Nursing home residents are D/G if Medicaid pays more than 50% of the cost
of care.

G

Effective 9/1/88, the State elected Federal administration of an optional State supplementary
payment to residents of title XIX facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- Individuals and couples in licensed medical facilities where
Medicaid is paying less than 50 percent of the cost of care, individuals and couples
in publicly operated community residences having 16 or less residents, and residents
of publicly operated emergency shelters throughout a month.

2. Coding and Monthly Payment Levels

New Jersey effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplementLevel

Total Payment Levels

A

A

All

623.00

150.05

773.05

B

All

623.00

31.25

654.25

C

Individual

623.00

336.36

959.36

w/EP

935.00

24.36

959.36

I

All

623.00

210.05

833.05

Z

All

623.00

0.00

623.00

B

D

All

415.341

44.31

459.65

C

B

All

623.00

31.25

654.25

D

G

All

30.003

10.00

40.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents the FBR plus EP increment.

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A

All

934.00

593.36

1527.36

B

All

934.00

25.36

959.36

I

All

934.00

713.36

1647.36

Z

All

934.00

0.00

934.00

B

D

All

622.671

93.09

715.76

D

G

All

60.002

20.00

80.00

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

L. Description of Supplements - New York

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Living Alone -- Eligible individuals or eligible couples who:

1.

Live physically alone.

2.

Pay a fixed, pre-established flat fee for both room and board in a commercial establishment.

3.

Lives with others but takes all meals outside the dwelling.

4.

Live with others but separately prepares or has someone separately prepare his/her
food. Occasional preparation of meals in common will not preclude a finding of separate
preparation.

5.

Receive a fixed, pre-established flat fee for room and board from all others in the dwelling.

6.

Live with only a foster child, or a homemaker authorized by the local department of
social services (DSS), or a family care recipient placed by: the Office of Mental
Health (OMH) or Office of Mental Retardation and Developmentally Disabilities (OMRDD)
or local DSS.

7.

Have no permanent living arrangement (i.e., transient or street person) and is not
with a spouse or a child for whom they have primary responsibility.

B

Living with Others -- Individual/child/couple who:

1.

Resides in a dwelling with others and prepares food in common with at least one other
person in the dwelling. Note - An individual living with an ineligible spouse must be considered living with others
despite any separate preparation. The same is true if an individual/couple lives with
a child for whom he/she has primary responsibility (except if the child is a foster
child).

2.

Is a child who does not meet the criteria for OSS C or OSS D (below).

3.

Lives in a religious community and room and/or board is provided in full or in part
by the religious community.

4.

Has no permanent living arrangement (i.e., transient or street person), but is with
an ineligible spouse or child for whom they have primary responsibility.

C

Congregate Care Level I –

1.

Individual/couple/child has been placed in a family type home certified by NYS Office
of Children and Family Services and supervised by a local DSS.

2.

Individual/couple/child has been placed in a family care home certified by OMH/OMRDD.

D

Congregate Care Level II – Payable to an eligible individual/couple/child who is a
resident of a licensed level 2 care facility. These consist of facilities, which provide
supportive living environments and include: Residences for Adults certified by the
NYS Department of Health; Privately operated facilities certified by the NYS OMH;
Privately-operated facilities certified by the NYS OMH and OMRDD; and Privately-operated
facilities certified by OASAS.

E

Congregate Care Level III -- Enhanced Residential Care

Payable to an eligible individual/couple who is a resident of a licensed level 3 care
facility which includes: Adult Homes and Enriched Housing programs certified by the
NYS Department of Health or Schools for the Mentally Retarded certified by the NYS
Office of Mental Retardation and Developmental Disabilities. Schools for the Mentally
Retarded usually meet the basic Federal definition of institution and consist of residential
facilities that provide academic, vocational, recreational and social skills programs.
Although sometimes called schools, they often do not meet the Federal definition of
schools. NOTE - A child residing in a Level 3 facility cannot receive OSS E; he/she will receive
OSS B.

F

Living in the Household of Another -- Payable to recipients who are FLA B.

G

Effective 1/1/88, the State elected Federal administration of an optional State supplementary
payment to residents of title XIX facilities. Federal administration was terminated
effective 9/30/03. State began administering this payment 10/1/03.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases – Includes Eligible individual/couple in FLA A or B who:

1.

Is in a licensed medical facility where Medicaid is paying less than 50% of the cost
of care; or

2.

Is in a publicly operated community residence which serves 16 or fewer residents;
or

3.

Is in a publicly operated emergency shelter (PESH); or

4.

Qualifies under the special provision in SI 00520.130 (1619 eligible goes into medical institution).

5.

Effective 10/1/03 eligible individual/couple in FLA D and also cases that were FLA
D prior to January 1988.

6.

Effective 12/1/96, children under age 18 residing in certain public or private facilities
receiving payment for their care under any health insurance policy issued by a private
provider (SI 00520.011).

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

4New York administers a supplement of $20 to some recipients in a title XIX institution.

M. Description of Supplements - Pennsylvania

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Living Alone -- Recipients in private medical facilities (nursing homes, hospitals,
intermediate care facilities) where title XIX is not paying more than 50 percent of the cost of care, residents of publicly operated emergency
shelters throughout a month, and all other individuals and couples in Federal codes
A and C not meeting the definition of another variation.

Used with an “intervening” Federal code A. (See SM 01301.535.)

This State code is also used to supplement Section 1619 cases.

B

Living in the Household of Another -- Recipients who do not have an EP and who live
in the household of another and receive support and maintenance for Federal purposes.

C

Living with an EP -- Recipients who are not living in the household of another or
in a foster care home for adults and who have one or more EP’s as defined under the
Federal rules.

D

Living in the Household of Another with an EP --Recipients who live in the household
of another and who have one or more EP’s as defined under the Federal rules.

G

Living in a Domiciliary Care Facility -- Adult persons (age 18 and over) certified
by the State to be residing in non-medical residential care facilities.

H

Living in a Personal Care Boarding Home -- Adult Persons (age 18 and over) certified
by the State to be residing in non-medical residential care facilities.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

Z

No Supplement Cases -- Includes all recipients who are residing in a medical facility
in which title XIX is paying more than 50 percent of the cost of care.

2. Coding and Monthly Payment Levels

Pennsylvania effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

Z

All

623.00

0.00

623.00

C

All

935.001

43.70

978.70

G

All

623.00

389.30

1012.30

H

All

623.00

439.30

1062.30

B

Z

All

415.342

0.00

415.34

D

All

623.343

43.70

667.04

C

Z

All

623.00

0.00

623.00

D

Z

All

30.004

0.00

30.00

1Not an FBR; the amount represents the FBR plus EP increment.

2Not an FBR; the amount represents the FBR less VTR.

3Not an FBR; the amount represents the FBR plus EP increment less VTR.

4Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

State Supplement Level

Total Payment Levels

A

A

All

934.00

0.00

934.00

C

All

1246.001

68.05

1314.05

G

All

934.00

857.40

1791.40

H

All

934.00

957.40

1891.40

B

B

All

622.672

0.00

622.67

D

All

830.673

68.05

898.72

D

Z

All

60.004

0.00

60.00

1Not an FBR; the amount represents the FBR plus EP increment.

2Not an FBR; the amount represents the FBR less VTR.

3Not an FBR; the amount represents the FBR plus EP increment less VTR.

4Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

N. Description of Supplements - Rhode Island

1. Definitions of State Living Arrangement Variations

Definitions of State Living Arrangement Variations are as follows:

Code

Definition

A

Independent Living -- Recipients who are in Federal codes A and C, except for individuals
residing in a residential care/assisted living facility who have been certified as
eligible for State Code D. This includes children under the age of 18 who are in Federal
living arrangement D because a private health insurance policy or a combination of
Medicaid and a private health insurance policy pays or is expected to pay over 50
percent of the cost of care for that month. See SI 00520.011C.1.b, second and third bullets.

Recipients residing in a public emergency shelter for the homeless and those who are
eligible for Section 1619 are included in this category.

B

Living in the Household of Another -- Recipients who are living in the household of
another and receiving support and maintenance in-kind. This variation applies only
when the one-third reduction to the Federal benefit is applied.

D

Residential Care/Assisted Living -- This category applies to individuals only.

E

The State elected Federal Administration of an optional State Supplementary payment
to residents of Title XIX Facilities (Effective 3/1/91). This includes children under
the age of 18 for whom Medicaid alone pays or is expected to pay over 50 percent of
the cost of care for that month.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

2. Coding and Monthly Payment Levels

Rhode Island effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A1

All

623.00

57.35

680.35

D

All

623.00

575.00

1198.00

B

B1

All

415.342

69.94

485.28

C

A1

All

623.00

57.35

680.35

D

A3

Children Private Insurance

30.004

57.35

87.35

E

All

30.004

20.00

50.00

1Code is systems generated from the Federal code.

2Not an FBR; the amount represents the FBR less VTR.

3State OS Code A applies to children under the age of 18 who are in Federal living
arrangement D because of private health insurance payments.

4Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplement Level

Total Payment Levels

A

A1

All

934.00

108.50

1042.50

B

B1

All

622.672

128.50

751.17

D

E

All

60.003

40.00

100.00

1Code is systems generated from the Federal code.

2Not an FBR; the amount represents the FBR less VTR.

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

O. Description of Supplements - Utah

1. Definitions of State Living Arrangement Variations

Code

Definition

A

Living Alone or With Others -- This variation includes recipients who are in Federal
codes A and C.

B

Living in the Household of Another -- Recipients with no EP who are “living in the
household of another” for Federal purposes. (Children under age 18 are included in
this living arrangement variation.)

Z

No Supplement Cases -- No supplement cases include all recipients who are not included
in A or B.

2. Coding and Monthly Payment Levels

Utah effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

State SupplementLevel

Total Payment Level

A,C

Z

All

623.00

0.00

623.00

B

B

All

415.342

3.13

418.47

D

Z

All

30.001

0.00

30.00

1Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

2Not an FBR, the amount represents the FBR less VTR.

b. Couple

Federal Code

State OS Code

Category

FBR

State

SupplementLevel

Total Payment Levels

A,C

A

All

934.00

4.60

938.60

B

B

All

622.672

9.73

632.40

D

Z

All

60.001

0.00

60.00

1Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

2Not an FBR, the amount represents the FBR less VTR.

P. Description of Supplements - Vermont

1. Definitions of State Living Arrangement Variations

Definitions of State Living Arrangement Variations

Code

Definition

A

Independent Living (except Chittenden County) -- Recipients not living in the household
of another and not in a residential or custodial care situation. This includes a child
who is living with a parent and recipients residing in a private title XIX facility
where Medicaid is not paying more than 50 percent of the cost of care. It includes
children under the age of 18 who are in Federal living arrangement D because a private
health insurance policy or a combination of Medicaid and a private health insurance
policy pays or is expected to pay over 50 percent of the cost of care for that month.
See SI 00520.011C.1.b, second and third bullets.

An individual or eligible couple residing in a publicly operated emergency shelter
throughout a month.

B

Independent Living in Chittenden County -- Same as Code A above except restricted
to residents of Chittenden County.

C

Licensed Residential Care Home or Assisted Living Residence with Assistive Community
Care Services (Level III) -- Recipients residing in Level III facilities identified
by the State. Refer to the Vermont Community Care Facilities (OS C and G) list on
BOSNet to determine if a residence meets the requirements for Optional Supplement
C.

E

Living in the Household of Another -- Recipients living in the household of another
and receiving support and maintenance (subject to the Federal one-third reduction
provisions).

G

Licensed Residential Care Home or Therapeutic Community Residence (Level IV) -- Recipients
residing in Level IV facilities identified by the State. Refer to the Vermont Community
Care Facilities (OS C and G) list on BOSNET to determine if a residence meets the
requirements for Optional Supplement G.

H

Custodial Care: Family Home -- Recipients living in another's home in such a manner
that the individual or couple is paying room and board and is receiving one or more
of the services outlined under the custodial care definition. The individual or couple
must also receive the room and board and custodial care in the home in which he/she
(they) reside. In order to qualify as a home under this arrangement, these services
must not be provided to more than two persons and must be provided by a resident of
the home.

In some cases the Vermont Department of Disabilities, Aging, and Independent Living
(DAIL) has established outplacement programs meeting the definition of L/A H. To qualify
these programs must meet the requirements stated above.

Custodial
care means providing basic room and board, plus personal services such as: help with feeding, dressing, bathing, moving about under
normal circumstances, occasional tray service (tray service 2-3 times a week) and/or
supervision for the recipient's protection. Supervision for the recipient's protection
deals primarily with protection services for retarded and emotionally disturbed individuals.
A person who receives one or more of these personal services is receiving custodial
care.

I

Effective 7/1/87, the State elected Federal administration of an optional State supplementary
payment to residents in title XIX facilities. This includes children under the age
of 18 for whom Medicaid alone pays or is expected to pay over 50 percent of the cost
of care for that month.

Y

Optional Supplementation Waived -- Individual is eligible for, but has waived his/her
right to receive, an optional supplement.

2. Coding and Monthly Payment Levels

Vermont effective 1/1/07.

a. Individual

Federal Code

State OS Code

Category

FBR

State

SupplementLevel

Total Payment Levels

A

A

All (Except Chittenden County)

623.00

52.04

675.04

B

All (Restricted to Chittenden County)

623.00

52.04

675.04

C

All

623.00

48.38

671.38

G

All

623.00

223.94

846.94

H

All

623.00

98.69

721.69

B

E

All

415.341

39.30

454.64

C

A

All (Except Chittenden County)

623.00

52.04

675.04

B

All (Restricted to Chittenden County)

623.00

52.04

675.04

D

A or B2

Children Private Insurance

30.003

52.04

82.04

I

All

30.003

17.66

47.66

1Not an FBR; the amount represents the FBR less VTR.

2State OS Code A or B applies to children under the age of 18 who are in Federal living
arrangement D because of private health insurance payments.

3Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.

b. Couple

Federal Code

State OS Code

Category

FBR

StateSupplementLevel

Total Payment Levels

A

A

All (Except Chittenden County

934.00

98.88

1032.88

B

All (Restricted to Chittenden County

934.00

98.88

1032.88

C

All

934.00

96.77

1030.77

G

All

934.00

562.06

1496.06

H

All

934.00

332.82

1266.82

B

E

All

622.671

48.31

670.98

D

I

All

60.002

35.33

95.33

1Not an FBR; the amount represents the FBR less VTR.

2Not an FBR; the amount represents a payment cap to recipients in a title XIX institution.